problendoПроблемы ЭндокринологииProblems of Endocrinology0375-96602308-1430Endocrinology Research Centre10.14341/probl10026problendo-10026Research ArticleКлинические случаиCase ReportsМанифестация диффузного токсического зоба у женщины с пангипопитуитаризмом, развившимся в результате радиохирургического лечения акромегалииManifestation of Graves’ disease, resulting from radiosurgical treatment of acromegaly, in a patient with panhypopituitarismhttps://orcid.org/0000-0003-4480-1902АстафьеваЛюдмила ИгоревнаAstafyevaLudmila I.

д.м.н.

MD, PhD

last@nsi.ruhttps://orcid.org/0000-0001-9333-9473КалининПавел ЛьвовичKalininPavel L.

д.м.н.

MD, PhD

pkalinin@nsi.ruhttps://orcid.org/0000-0001-9205-8979КиеняТатьяна АлександровнаKieniaTatyana A.

аспирант

MD

tatyana2336@yandex.ruhttps://orcid.org/0000-0002-2504-7468ФадеевВалентин ВикторовичFadeyevValentin V.

д.м.н., профессор, член-корр. РАН

MD, PhD, Professor

walfad@mail.ruФГАУ «Нaциональный медицинский исследовательский центр нейрохирургии им. акад. Н.Н. Бурденко» Минздрава РоссииРоссияN.N. Burdenko national medical research center of neurosurgeryRussian FederationФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова (Сеченовский университет)» Минздрава РоссииРоссияI.M. Sechenov First Moscow State Medical University (Sechenov University)Russian Federation201930062019652101106Copyright © Астафьева Л.И., Калинин П.Л., Киеня Т.А., Фадеев В.В., 20192019Астафьева Л.И., Калинин П.Л., Киеня Т.А., Фадеев В.В.Astafyeva L.I., Kalinin P.L., Kienia T.A., Fadeyev V.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.probl-endojournals.ru/jour/article/view/10026

Случаи манифестации тиреотоксикоза на фоне предшествующего вторичного гипотиреоза крайне редки. В статье представлено клиническое наблюдение манифестации диффузного токсического зоба у пациентки с вторичным гипотиреозом, развившимся после радиохирургического лечения акромегалии.

Пациентке 38 лет с акромегалией и эндо-супра-латероселлярной аденомой гипофиза после нерадикального удаления было проведено радиохирургическое лечение остаточной ткани опухоли гипофиза в области кавернозного синуса. Через 14 мес достигнута ремиссия акромегалии, через 24 мес после лучевого лечения развился пангипопитуитаризм (вторичный гипотиреоз, гипокортицизм, гипогонадизм, СТГ-дефицит). Однако через 1,5 года после диагностики пангипопитуитаризма была отмечена манифестация диффузного токсического зоба, что потребовало тиреостатической терапии и радиойодтерапии.

Диагностическими критериями вторичного гипотиреоза является низкое содержание тиреоидных гормонов (св. Т4 и св. Т3) при сниженной, нормальной или слегка повышенной концентрации ТТГ. Критерием развития тиреотоксикоза на фоне вторичного гипотиреоза было стойкое повышение концентрации св. Т4 на фоне адекватной терапии левотироксином. Выявление высокой концентрации антител к рецептору ТТГ в описанном случае подтвердило манифестацию диффузного токсического зоба.

Cases of thyrotoxicosis associated with a previous case of secondary hypothyroidism are extremely rare. This article presents a rare clinical case of Graves’ disease manifestation in a patient with secondary hypothyroidism after radiosurgical treatment of acromegaly. A 38-year old woman presented with acromegaly and endo-supra-laterosellar pituitary adenoma. After non-radical removal of the pituitary adenoma, radiosurgical treatment of the of the residual tissue of the pituitary tumor in the cavernous sinus area was performed. After 14 months of radiation therapy, the acromegaly was in remission; after 24 months of radiation therapy, panhypopituitarism developed (secondary hypothyroidism, adrenal insufficiency, hypogonadism, and growth hormone deficiency). Furthermore, 1.5 years after the panhypopituitarism was diagnosed, the manifestation of Graves’ disease was also noted, requiring thyrostatic and radioactive iodine treatments.

Diagnostic criteria for secondary hypothyroidism are low levels of the thyroid hormones free T4 and free T3, with a reduced, normal or slightly elevated level of thyroid stimulating hormone (TSH). The criterion for the development of thyrotoxicosis in the context of the secondary hypothyroidism was the persistent increase in the level of free T4 despite adequate drug therapy with levothyroxine. In the case report, the patient’s diagnosis of Graves’ disease was confirmed by the presence of a high level of antibodies to the TSH receptor.

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The authors declare that there are no conflicts of interest present.